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Tending to the Dying in Hospitals


By Jean Kutner, MD

By definition, most doctors focus on making people well and keeping them that way. The notion of palliative and end-of-life care can rub against the grain of that life-saving, life-preserving concept.

That helps explain why so many hospitals and educational institutions have only recently embraced the idea of palliative care.

Hospice and Palliative Medicine was recognized as a specialty by the American Board of Medical Specialties in September 2006.

In October 2008, University of Colorado Denver School of Medicine faculty members Jeanie Youngwerth, MD; David Nowels, MD; Sue Meyer, MD; and I took the first board certification exam.

On Feb. 5, we found out that we all passed, making us among the first physicians in the country to be board certified in hospice and palliative medicine.

The relative value of investing in the comfort of those who are not likely to recover raises questions. I'm going to try to answer some of those questions.

First, my training as a physician teaches me that I am duty-bound to provide the most comfort that I can to the patients I treat. The oaths that I take as a doctor call on me to care for the dying with the same zeal that I afford those who will survive.

I became a palliative care specialist after watching people die in hospitals not realizing they were close to death because no one told them. Some of those people died without family members present who could have and should have been there.

In medicine generally, doctors often perceive death as a failure. We need to be aware that death is part of the natural process.

People in this country used to die at home. Now, they too often die in intensive care units or other acute care settings that are not, generally, focused on enhancing the quality of their final days.

In the past decade, the country has started to recognize this, and great strides have been made in improving care for people with advanced illness and limited life expectancy.

The Center to Advance Palliative Care recently completed a study of access to end-of-life treatment across the country (Here's the link:

Researchers found mixed results. Basically, where you live plays a big role in how you die. If you live in Colorado, you're in pretty good shape. Roughly two out of three hospitals in the state have palliative care programs. That rates a "B" on the national grading scale.

Vermont, where 100 percent of hospitals offer palliative care, and Montana, where 88 percent of hospitals have a palliative care program, led the way. Mississippi, with only one in 10 hospitals offering these programs, lags the pack.

The Centers for Medicare and Medicaid recently recognized palliative care as a specialty for billing purposes.

But palliative care is about more than hospital programs, Medicare and Medicaid reimbursements and board certifications. It is about more than saving money, even though letting people die at home or in less intense hospital settings saves money.

Palliative care revolves around what it should - what people want at the end of their lives. As doctors, we always try to prolong life as long a possible.

But we are growing more comfortable with and have a growing evidence base to help with approaches that relieve pain and suffering for those with advanced and terminal illness.

We are growing more comfortable asking why we utilize resources such as intensive care units for patients who are not likely to benefit.

We have begun to increase the focus on letting people spend their last days in their preferred place of death. For many Americans, that is at home.

End-of-life choices should reflect the individual's goals and values, whatever they are.

Americans do not necessarily fear dying. They fear pain; they fear losing control; they fear losing dignity. When our health care system can treat all of those symptoms and concerns, palliative care will have realized its potential.

Jean Kutner, MD, is an Associate Professor and Division Head of General Internal Medicine at the University of Colorado Denver School of Medicine.

The University of Colorado Denver School of Medicine faculty work to advance science and improve care as the physicians, educators and scientists at University of Colorado Hospital, The Children’s Hospital, Denver Health, National Jewish Health, and the Denver Veterans Affairs Medical Center. Degrees offered by the UC Denver School of Medicine include doctor of medicine, doctor of physical therapy, and masters of physician assistant studies. The School is part of the University of Colorado Denver, one of three campuses in the University of Colorado system. For additional news and information, please visit the UC Denver newsroom online.